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Unit 13 > Respiratory Examination Lecture > Flashcards

Respiratory Examination Lecture Flashcards

1
Q

What are the cardinal respiratory symptoms?

A

Breathlessness
Cough
Sputum
Haemoptysis
Chest pain
Hoarseness.

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2
Q

What are the potential different broad causes of breathlessness?

A

Lung - RR, hyperinflamation, inflammation
Heart - heart failure, vascular problem
Brain - anxiety,anger, low mood, attention to sensation, misconceptions about death
Muscles - respiratory muscle fatigue, inefficient breathing patterns (paradoxical breathing)

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3
Q

What features are important to ask clinically when a patient presents with breathlessness?

A

Acute/chronic - onset/severity
Continuous or episodic
Limitation aka exercise intolerance and if this is variable
Co-symptoms and relief factors to rule out differentials.

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4
Q

What is the MRC dyspnoea scale?

A

Score is based on the degree of breathlessness related to activity
1. Not troubled by breathless except on strenuous exercise
2. SOb when hurrying or walking up a slight hill
3. Walk slower than most on the level, stops after amile or stops after 15mins at own pace
4. Stops for breath after 100 yards or few minutes on level ground
5. Too breathless to leave the house, dress/undressing.

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5
Q

What is the ECOG/Who score related to breathlessness?

A

Assesses patients functioning through their ability to care for themselves.
0 - fully active, predisease activity without restriction.
1 - restricted in strenous activity, but is ambulatory and able to complete light/sednetary work e,g office job, some house work
2 - ambulatory and able to self care but can not work, is mobile for 50% of walking hours
3 - only limited self care, confined to bed/chair for more than 50% of waking day
4 - completely disabled, no self care, confined to bed/chair
5 - dead.

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6
Q

What features are important to ask abuot a cough?

A

Acute/chronic
Wet/dry
Time of day - variable, when do they first cough aka when getting up out or bed (change from lying to standing)
Relation to GI eating, speaking, environmental and occupational triggers
Visual analogue scale to assess severity
ACE inhibitor history
LCQ - patient questionnaire, graded answers to assess affect on quality of life.
New cough with no infection should prompt cancer assessment in current/ex smokers.

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7
Q

What do different types of sputum indicate?

A

Clear, mucoid - stable COPD
Yellow or greenish colour can indicate infection as purulent
Blood - PE, cancer, infection (note may also be from dental work or nosebleed that has bled back into phlegm then coughed up - particularly if in the morning).

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8
Q

What value is considered massive for coughing up blood?

A

Above 250ml in 24 hours.

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9
Q

What are the potential causes for someone to cough up blood?

A

Pulmonary hypertension
Severe mitral stenosis
Decompensated congestive left heart failure

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10
Q

What does stridor lung noise indicate?
What does it sound like?

A

Large airway obstruction
Abnormal high pitched sound, most commonly on inspiration.

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11
Q

How can an upper airway obstruction cause hoarsness of voice?

A

Tumour or disease process near the left main bronchi - can cause pressure on the left recurrent laryngeal nerve as it passes under the arch of the aorta
Reduces innervation to the voice box.

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12
Q

What are some of the potential causes of stridor in detail?

A

Naso/oropharynx - tonsilar hypertrophy, pharyngtitis, peritonsillar abcess or retropharangeal abscess
larynopharynx/larynx - epiglottis, paradoxical vocal cord movement, anaphylaxis, tumour, vocal cord paralysis
Trachea - tracheal stenosis, tracheomalacia, goiter.
Proximal airways - foreign body aspiration

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13
Q

What is vocal cord paralysis?

A

Unable to control muscles of vocal cords
Problem with innervation via the recurrent laryngeal nerve - can present with hoarseness of voice.
May be pulmonary (tumour on left main bronchi) or neurological (stroke or parkinsons) in origin.

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14
Q

What are the life-threatening causes of chest pain?

A

Tension pneuomthorax
Aortic dissection
Pulmonary embolus
Oesophageal rupture
Acute myocardial infarction/angina
Oesophageal rupture

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15
Q

What are some causes of chest pain ( likey not fatal)?

A

Shingles
Oesophageal spasm
Pneumonia
Cholecystitis
Pancreatitis
GERD/ulcers
Sickle cell crisis
Empyema
Pleurisy
Costochondritis
Bone mets
Rib fracture
Cervical spondylosis

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16
Q

What in the patients environment can indicate a respiratory condition?

A

Oxygen delivery devices - look for device such as nasal canulae, look at current rate of oxygen flow
Sputum pot - volume and colour
Cigarettes or vaping
Mobility aids
Vital signs
Fluid balance (heart failure)
Prescriptions
ECG leads, medications, catheters, IV access.

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17
Q

What is finger clubbing?

A

Uniform swelling of soft tissue of the terminal phalanx of a digit )fingers and toes)
Hence loss of normal angel between nail and nail bed.
Though to be caused by low oxygen levels increasing VEGF expression in extremities and remodelling tissue.

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18
Q

What can cause a fine tremor in a respiratory exam?

A

Fine tremor when arms are outstreched can indicate a beta 2 agonist use , also anxiety fatigue, hypothyroidism

19
Q

What can cause asterixis in a respiratory examination?

A

Irregular lapses of posture causes a flapping motion in hands when held out like stopping traffic (wrist extension for 30 seconds)
Caused by Co2 retention - type 2 respiratory failure
Also uraemia or hepatic encephalopathy.

20
Q

What is the normal respiratory rate?

A

12-20bpm
Above 20 = tachypnoea
Below 12bpm = bradypnoea

21
Q

What different locations on the chest should be checked for scars?
What do they indicate?

A

Midlein sternotomy - in midline of thorax - cardiac valve replacement or coronary artery bypass graft
Infraclavicular scar - Pacemaker
Anterolateral thoractomy - mid axillary line to sternal border - lobectomy or pneumocetomy
Posterolateral thoractomy - posterior scapular lower border to anterior axiallry line - lobectomy, pneumonectomy and oesophageal surgery.
Axillary thoracotomy - chest drain insertion

22
Q

What are the radiotherapy associated skin changes you may observe on a patient?

A

xerosis (dry skin)
Scale
Hyperkeratosis (thickened skin)
Depigmentation
Telangiectasia
Tattoos for placement of radiotherapy machine.

23
Q

What chest wall deformities should you check for in the respiratory examination?

A

Asymmetry - pnemonectomy and thoracoplasty.
PEctus excavatum - (breastbone and ribs grow inwards creating a dint in the chest) caused by Marfan Syndrome (other genetic inherited conditions), vitamin D deficiency
Pectus carinatum - pigeon chesting, excessive growth of cartilage and breast bone, Asthma, marfan syndrome, vitamin D deficiency.

24
Q

What measurements should you take of the chest wall in the respiratory examination?

A

Chest expansion - broad hands on chest, thumb off, look at movement of thumbs.
Cricosternal distance - trachea can deviate away from tension pneumothorax and large pleural effusions, trachea deviates towards global collapse and pneumoectomy, palpate trachea to feel.

25
Q

What does hyperexpansion of the chest look like on a respiratory examination?

A

Chest wall appears wider and taller than normal
AP (anterior posterior) to lateral ratio: normal value is 1:2, closer to 1:1 can indicate hyperinflation.
Observed with obstructive lung diseases such as COPD.

26
Q

Why do we assess chest wall expansion?
What are some of the normal values?

A

Should be around 2cm
Symmetrical change can indicate _ parenchymal lung disease, particularly restrive disease.
Asymetrical change: pneumothorac, pneumonia and pleural effusion.

27
Q

Where should we percuss on the chest?
What should is normally sound like?

A

Supraclavicular region for lung apices
Infraclavicular region
Chest wall: 3-4 location bilaterally
Axilla
Should normally be resonant.

28
Q

What do different percussion sounds on the chest indicate?

A

Dullness - suggest increased tissue desnity - (consolidation or collapse)
Stony dullness - pleural effusion
Hyper-resonance - not really clinically determinable.

29
Q

What is the test for tactile vocal fremitus or vocal resonance?

A

tactile vocal fremitus - place palm of hand over chest ask patient to say 99, feel for vibration in the chest wall

Vocal resonance - use stethoscope to asuculate the chest, ask patient to say 99 at each point over the chest.

30
Q

What do abnormal results of tactile vocal fremitus or vocal resonance indicate?

A

Increased vibration/resencens - increased tissue density (tumour, consolidation, lobar collapse)
Decreased vibration/resonance - presence of fluid or air outside the lung (pleural effusion, pneumothrax)

31
Q

What are the different breath sounds?

A

Vesciualr - normal
Bronchial
Quiet breath sounds
Wheeze
Stridor
Coarse crackles
Fine end respiratory crackles.

32
Q

What causes bronchial breath sounds?
What does it sound like?

A

Harsh -sounding
Inspiration and expiration are equal, with pause between them
Associated with consolidation.

33
Q

What causes quiet breath sounds?

A

Reduced air entry into the lung
Pleural effusion, pneumothorax

34
Q

What causes a wheeze breath sound?
What does it sound like?

A

Wheeze - continuous, whistling sound caused by turbulent airflow.
Polyphenic - obstruction commonly asthma
Or monophonic (upper large airway obstruction)
Mainly heard on expiration

35
Q

What causes a stridor lung sound?
What does it sound like>

A

Mainly heard in inspiration
Is a high pitched, extra-thoracic breath sound from turbulent airflow through narrowed upper airway
Large airway obstruction
Exadurated by huffing

36
Q

What causes a coarse crackles lung sound?
What does it sound like?

A

Discontinuous, brief, popping lung sound towards the end of inspiration
Pneumonia, bronchiectasis and pulmonary odema

37
Q

What causes a fine crackles lung sound?
what does it sound like>

A

Velcro ripping like noise towards the end of inspiration.
Pulmonary fibrosis

38
Q

What lymph nodes should be assessed in the respiratory examination?

A

Submental and submandibular
Pre-auricular and post auricular
Cervical chains
Supraclavicular - (left supraclavicular for Virchows node)
Auxillary

39
Q

Why do we check for peripheral odema in respiratory exam?

A

Sign of RHF
Hypoalbuminaemia (link to pulmonary odema)
Immobility.

40
Q

What are the two different phenotypes of COPD?

A

Blue bloater - chronic bronchitis
Pink puffer - emphysema

41
Q

How does a patient in COPD with mainly chronic bronchitis present?

A

Blue bloater
Chronic productive cough
Purulent sputum
Hemoptysis
Mild dyspnea initially
Cyanosis
Peripheral edema
Crackles and wheeze
Prolonged expiration
Obese

42
Q

What are the potential complications of chronic bronchitis in a COPD patient?

A

Secondary polycythemia vera due to hypoxemia
Pulmonary hypertension due to reactive hypoxic vasconstriction
Cor pulmonale from chronic pulmonary hypertension

43
Q

How does a patient with emphysema phentype in COPD present?

A

Dysnpnea
Minimal cough
increased minute ventilation
Pink skin
Pursed lip breathing
Accessory muscle loss
Cachexia
Hyperinflation (barrel chest)
Decreased breath sounds
Tachypnea.

44
Q

What are some of the complication of emphysema?

A

Pneumothorax due to bullae
Weight loss due to work of breathing.

Unit 13 (22 decks)

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